Clinical Guidelines for Chiropractic Practice in Canada
Chapter 7 - Clinical Impression and Diagnosis
Chapter Outline
I. OVERVIEW
Diagnosis is an art as well as a science. According to Wulff (1976) a diagnosis may be characterized as a mental resting place for therapeutic decisions and prognostic considerations.
As a matter of clinical process a diagnosis is often preceded by a clinical impression or working diagnosis. A further concept common to chiropractic practice is that of analysis. This chapter discusses and defines these concepts, then provides basic guidelines for practice.
II. DEFINITIONS
For definitions see the Glossary at the end of this publication.
Analysis
Clinical Impression
Diagnosis
III. SUB-TOPICS
1. Clinical impression
2. Diagnosis
3. Terminology
4. Differential diagnosis
IV. LITERATURE REVIEW
The term 'analysis' is frequently used in chiropractic literature and practice and should be understood in its historical context. D. D. Palmer (1910) in his explanation of vertebral subluxation stated that "Chiropractic analysis is the art of finding the offending vertebrae by palpation".
Because of Palmer's use of the term 'analysis', and because of the legal ramifications of use of the term 'diagnosis' by chiropractors in the early years of this century, many in the chiropractic profession made exclusive use of the term `analysis' in describing all chiropractic methods associated with the formation of a clinical impression and diagnosis. By the middle of the century Janse (1947) and others explained that a spinal analysis or chiropractic analysis in the sense described by Palmer was an important component of, but insufficient in itself to make, a diagnosis. In modern usage the term `analysis' is frequently used by the chiropractic and other health professionals in the context of decision analysis, a process which like diagnosis is more of an art than a science (Kassirer et al, 1987; Pauker and Kassirer, 1987).
A diagnosis, according to Jaquet (1974), represents the global evaluation of the patient from an organic, functional, psycho-emotional and social viewpoint. It suggests a greater degree of precision and certainty than a clinical impression, which refers to a preliminary or working diagnosis.
There is general acceptance that the taking of a thorough case history is the single most important aspect in arriving at a clinical impression or diagnosis. Additional important information comes not only from examination and a variety of diagnostic procedures but also the response to initial treatment. This response may either confirm or undermine the early clinical impression, and be important in arriving at a diagnosis (Kirkaldy-Willis, 1988).
While the term 'diagnosis' denotes greater exactness, firmness and clarity, the process of arriving at then reviewing a diagnosis is as much art as science. Henrik Wulff (1976) gives emphasis to this by referring to diagnosis as a mental resting place for therapeutic decisions and prognostic considerations. This is a useful image in implying likely future change and the need for constant review of information in order to verify or alter any diagnosis reached.
I. ASSESSMENT CRITERIA
Rating Systems 2 assessment criteria are used in this chapter. For an explanation of this system see the Introduction and Guide to Use (p. xxiii).
II. RECOMMENDATIONS (GUIDELINES)
A. Clinical Impression or Working Diagnosis:
7.1 In the absence of a clear diagnosis a working diagnosis or clinical impression must be made, and must be communicated to the patient and recorded prior to treatment.
Rating: Necessary
Evidence: Class I,II, III
Consensus level: 1
A. Diagnosis:
7.2 Where a diagnosis is made, it must be communicated to the patient and recorded prior to treatment.
Rating: Necessary
Evidence: Class I, II, III
Consensus level: 1
B. Differential diagnosis:
7.3 One aspect of reaching a clinical impression or a diagnosis should be a consideration of all potential causes of the patient's complaint, and whether or not there may be a need for referral.
Rating: Necessary
Evidence: Class I,II,III
Consensus level: 1
C. Terminology
7.4 Diagnostic terms should be used in a manner that is consistent with generally accepted usage in the chiropractic profession.
Rating: Necessary
Evidence: Class I, II, III
Consensus level: 1
II. COMMENTS, SUMMARY OR CONCLUSION
The proposed guidelines represent a baseline or starting point in the delineation of this area. Further input and ideas will help flesh this area out.
III. REFERENCES
Agnew, et al., eds. Dorland's Illustrated Medical Dictionary. 24th ed. Philadelphia: Saunders, 1965.
Albert D, Munson R, Resnik M. Reasoning in medicine: an introduction to clinical inference. Baltimore: The Johns Hopkins University Press, 1988: 181-182.
Hampton JR, Harrison MJG, et al. Relative contributions of history-taking, physical examination and laboratory investigation to diagnosis and management of medical outpatients. Br Med J 1975; 2:486-498.
Janse J, Houser RH, Wells B. Chiropractic principles and technic. Chicago: National College of Chiropractic, 1947.
Jaquet P. An introduction to clinical chiropractic. Geneva: Grounauer, 1974.
Kassirer J, Moskowitz A, Lau J, Pauker S. decision analysis: a progress report. Ann Int Med 1987; 106(2):275-291.
Kirkaldy-Willis WH. Making a specific diagnosis. In: Kirkaldy-Willis WH (ed). Managing Low Back Pain. 2nd ed. New York: Churchill Livingstone, 1988: 209-228.
Palmer DD. The Chiropractor's Adjuster. The science, art and philosophy of chiropractic. Portland: Portland Printing House Company, 1910.
Pauker S, Kassirer J. Decision Analysis. New Eng J Med 1987; 316(5):250-258.
Henderson DJ. Vertebral artery syndrome. In: Vear HJ, ed. Chiropractic standards of practice and quality of care. Gaithersburg: Aspen Publishers, Inc, 1992:114-144.
Wullf H. Rational diagnosis and treatment. Oxford: Blackwell Scientific Publications, 1976.
I. MINORITY OPINIONS |